Provider Demographics
NPI:1417983693
Name:GULF COAST KIDNEY CENTER INC
Entity Type:Organization
Organization Name:GULF COAST KIDNEY CENTER INC
Other - Org Name:PHYSICIANS DIALYSIS TRINITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-651-3261
Mailing Address - Street 1:19559 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:N MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-3501
Mailing Address - Country:US
Mailing Address - Phone:305-651-3261
Mailing Address - Fax:305-651-2961
Practice Address - Street 1:9332 STATE ROAD 54
Practice Address - Street 2:SUITE 306
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1810
Practice Address - Country:US
Practice Address - Phone:727-848-0106
Practice Address - Fax:727-848-7943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL209147000Medicaid
FL102529Medicare Oscar/Certification